<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701118
Report Date: 05/09/2022
Date Signed: 05/11/2022 08:28:21 AM

Document Has Been Signed on 05/11/2022 08:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 4FACILITY NUMBER:
392701118
ADMINISTRATOR:KOAYEN, TANNEHFACILITY TYPE:
735
ADDRESS:4011 OAK VALLEY RDTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 4CENSUS: 0DATE:
05/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Tanneh KoayenTIME COMPLETED:
12:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/09/2022 at 9:20 am Licensing Program Analyst (LPA) T. White arrived announced to conduct a prelicensing inspection with applicant Tanneh Koayen for this adult residential facility application. Administrator Certification for Tanneh Koayen is #6030594735 that expires on 07/09/2023.

LPA conducted an inspection of facility including common areas, client bedrooms, bathrooms, kitchen, storage, and outside yard area. Requested capacity is 4 clients. The facility is clean and in good repair in areas toured. No hazards were noted in courtyard areas, hallways, doorways, etc. No equipment was stored in public areas. Fixtures and furniture all appear to be in good condition. Cleaning solutions are stored separately from food and are secured. There are no bodies of water on the premises. Smoke alarm was tested and operational. Fire extinguisher was in compliance and serviced June 11, 2022 and facility has carbon monoxide detectors.

Adequate number of bedrooms (4) for capacity requested. Facility has supply of bedding and towels. Furniture appears appropriate in bedrooms. There is adequate closet/drawer space available. there are adequate bathrooms for clients. Non-skid surfaces/mats were noted in the shower. Kitchen appears to be clean, well supplied with equipment. Facility has current staff files and adequate supply of forms. First aid kit was present at the facility. Laundry equipment present, working telephone, emergency lighting. Water temperature was measured at 118 degrees F.

LPA conducted Component III presentation.

Exit interview conducted and copy of this report was provided to applicant for signature. Report sent to the applications unit as this facility is ready for licensure.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1